Cholestasis of pregnancy: symptoms, risks and treatment

Tommy’s says the most common symptom is itching without a rash. It is often worse at night and more noticeable on the palms of the hands and soles of the feet, but it can be anywhere on the body. It can be mild or intense, affect small areas or all of the body, and be distressing and affect your sleep.

Other, less common symptoms listed by Tommy’s and NHS Wales are dark wee, pale poo, and yellowing of the skin and whites of the eyes (jaundice).

Both sources note that itching is very common in pregnancy and that only a small number of people who itch will have ICP, which is why it needs to be checked.

Intrahepatic cholestasis of pregnancy (ICP), sometimes called obstetric cholestasis, is a condition affecting the liver in pregnancy. NHS Wales describes it as a potentially serious liver disorder in which bile acids do not flow properly from the liver to the gut and build up in the body instead.

NHS Wales says there is no cure for ICP, but it should go once you have had your baby.

Tommy’s says that if you have any itching you should contact your maternity service within 24 hours and try to be specific about where you are itchy and how severe it is. NHS Wales says to call your midwife or GP if you have itching that is mild or distressing, possibly worse at night, anywhere on the body but especially the palms of your hands and soles of your feet.

Tommy’s says that if you are concerned but do not feel your symptoms are being taken seriously, you can ask to see another midwife or doctor.

It also says to call your maternity unit and go to get checked straight away if your baby is moving less, movements feel weaker, or movements have stopped.

Tommy’s says the causes are not fully understood but it is possibly due to a combination of hormonal, genetic and environmental factors, and it sometimes runs in families. If you take a thiopurine medicine (azathioprine, mercaptopurine or tioguanine) you may have a slightly higher risk of ICP, and of getting it earlier in pregnancy.

NHS Wales adds that ICP can happen even if there is no family history, that it is more common in women of south Asian origin, and that if you have had ICP in a previous pregnancy you have a high chance of developing it again. Tommy’s says it increases your chance of having it again in future pregnancies.

ICP is diagnosed by excluding other causes of the itching. Tommy’s says your doctor will check your skin to see if the itching could be due to a skin condition like eczema, and will probably advise blood tests including liver function and bile acids.

Some people may have itching for days or weeks before blood tests become abnormal, so Tommy’s says that if you are still itching and a cause has not been found, the blood tests should be repeated every 1 to 2 weeks.

Tommy’s says your baby is more likely to pass meconium (poo) before they are born, which can make them unwell if it gets into their lungs during labour, and is more likely to be born early (before 37 weeks). It says there is an increased risk of stillbirth for some people, but that for most the risk will be the same as for people without ICP. For people whose bile acid levels are 100 micromols per litre or more, it quotes a chance of stillbirth of around 3%.

It says there are no known long-term health risks to your baby from you having ICP, and that your baby has a slightly higher chance of needing time in a neonatal unit, especially if born early.

Tommy’s says there are not any treatments to improve your bile acid levels, but you are likely to be under the care of an obstetrician with a plan of care, with bile acid and liver function tests possibly every week at first. You will not need extra scans because you have ICP, but ICP makes you more likely to get pre-eclampsia or gestational diabetes, so your team will advise on checks.

For itching, Tommy’s says there is not good evidence for most treatments that have been tried. Loose cotton clothing, cool baths and unperfumed products may help, and safe skin creams such as aqueous cream (with or without menthol) may ease itching. It says ursodeoxycholic acid (UDCA) probably slightly improves itching for a small number of people, and that sedating antihistamines may help you sleep.

NHS Wales says UDCA can help reduce bile acids and ease itching and is considered safe in pregnancy, prescribed on an informed consent basis. A vitamin K supplement may be offered because ICP can affect vitamin K absorption, which matters for blood clotting, although Tommy’s says not many people need it.

NHS Wales says that because of the link with stillbirth you may be offered induction of labour, which could be any time from 35 weeks depending on the level of bile acids in your blood, and that you will probably be advised to give birth in hospital under a consultant-led maternity team.

Tommy’s says that depending on your bile acid levels and other risk factors such as pre-eclampsia, you may be asked to consider a planned birth by induction or caesarean section to reduce the chance of stillbirth, and that your pain relief options in labour are the same as for someone without ICP.

Tommy’s says ICP symptoms get better once you have given birth, but it can take a few weeks for blood tests to return to normal. You should have a bile acid test and liver function test around 6 weeks after birth to confirm this, and if results are not normal they will be repeated and you may be referred to a specialist.

It says having had ICP does not affect your choice of contraception once your liver blood tests and bile acid levels are normal again, and that some evidence suggests a slightly higher chance of liver problems in future, but extra screening or follow-up is not recommended.

ICP is managed within NHS maternity services under an obstetrician after you report itching to your midwife or GP. The charity ICP Support provides information and support, as pointed to by both sources.

Private obstetric care can offer the same blood tests and monitoring, but decisions about the timing of birth are made with your own maternity team based on your bile acid levels and any other risk factors.